Nineteenth Century Medical Guide

Chapter 452 448 Nice knot

Chapter 452 448. Nice knot

The deep fascia of the limbs penetrates deep into the muscle groups and connects to the bones, separating the muscle groups. These fascia will form osteofascial chambers. In addition to muscles, there are also many nerves and blood vessels that supply the limbs.

Because tissue edema and congestion edema locally compress the fascia around the bone fascial compartment, the pressure in the fascial compartment increases, which further compresses the small blood vessels inside and causes tissue ischemia, and then forms a vicious cycle of edema-ischemia-more edema.

This is what's happening to Devin's calf right now, a classic case of compartment syndrome.

However, in general, compartment syndrome occurs after a fracture caused by a high-energy impact and within 48 hours after the fracture surgery. Because that period is the middle inflammatory edema period after the tissue is subjected to violence, it is a normal pathological change. What doctors need to do is to evaluate the trauma and do a good job of prevention.

Devinke had no signs of compartment syndrome after surgery, his skin was taut but not strong, and nail infection was almost non-existent. As long as he followed everything Kavey said and recovered well, healing was only a matter of time.

Now, a week has passed since the operation, and his calf suddenly developed compartment syndrome, which was obviously abnormal. The direct reason for this was that he was disobedient and kept doing things recklessly. Young doctors like Peon and Albaran could not control him at all. Kawi didn't have time, and he didn't expect the other party to behave so exaggeratedly.

If Devin was in a large ward with multiple patients, Landreth might have stepped forward to help take care of it, but Devin was in a single room and it didn't affect other patients, so he was too lazy to take care of it.

Compartment syndrome has always been an invisible killer after a fracture. The root cause is that tissue edema compresses blood vessels and nerves. The reason for the compression is that the skin wraps the outside. Therefore, there is no need to hesitate to treat compartment syndrome. Just cut the skin and release the space in the compartment.

In theory, this type of incision requires anesthesia. If nerve block cannot be performed, ether general anesthesia will be required.

However, seeing that the nearly perfect four-pin external fixation of the tibial shaft fracture was destroyed by a jerk, Kavey had to find a place to vent his frustration. In addition, he had to teach Devin a lesson and make him remember what happened today next time he messes up.

As for ether, leave it to those who need it more.

Devin knew he couldn't dodge, and when he saw the two interns rushing towards him, he tactfully didn't move. He just grabbed the bed sheet with both hands with a sad face, ready to accept the baptism of fate.

But when fate came, it was too violent.

Compared to the screams just now, the room was now silent. Devinke was like a drowning man falling into the sea, with waves hitting his flushed face one after another. His muscles were so tense that he couldn't even breathe normally, and he had no energy left to shout.

This gave Kavi many teaching opportunities.

He pressed his whole hand on Devinke's knee, fixing his trembling and twisting limbs: "Do you see the concept of compartment syndrome I mentioned before?"

"Yes, I saw it. The skin is tight, the legs are obviously swollen, the pulse is weak, the sensation is abnormal, there is severe pulling pain, and the movement is obviously limited. Two blisters can be seen on his calves due to excessive tension, and the skin temperature is significantly lower than before."

Peon had a good memory and was very clear about what Kawi was talking about. In the past few days, he had visited the orthopedics department and seen many patients with fractures who had been fixed there. Many patients did have this condition. However, this was the first time he had seen such a direct treatment method in Kawi's hands.

Anyone who knows about compartment syndrome can see what Kawi is trying to do when the surgery is done at this stage. "Is Dr. Kawi going to cut open the skin and the fascia covering the compartment to release the pressure?"

"Yes, I mentioned it before when I was operating on him, but this situation did not occur at that time."

Devinke's calf was shaking constantly, and it would be difficult for ordinary people to operate in this situation, but Kavey did not hesitate. He cut very steadily and very quickly. He first made a straight incision on the anterior and lateral side, which was longer than the incision made during the operation: "From the tibial tuberosity to the lateral condyle, the length depends on the situation, usually 5-8cm, and it doesn't matter if it's longer."

“Just cut it like this?”

"It's useless to simply cut the skin. We also need to cut the fascia, and the length must be sufficient. It will take about 10 days for the pain to completely subside." Kawi looked up at Devinke, who was a little dazed by the pain. "Bear with it, it will be healed soon."

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The anterolateral incision requires further incision of the fascia overlying the anterior compartment (blue) and lateral compartment (green) to release lateral pressure.

However, for a location like the calf where there are many fascial compartments, a unilateral incision is not safe. In line with the principle of not letting go of one by mistake, Kawi had to make another incision:
"Generally, when a tibial fracture occurs, bilateral decompression is performed. The previous one was the anterior and lateral side, and the next one is the posteromedial side, which is parallel to the bottom of the surgical incision. It should be noted that an 8cm skin bridge must be ensured between the two incisions, otherwise there will be a risk of necrosis and rupture."

If there is a syndrome before or after surgery, the original surgical incision does not need to be sutured, and only an anterior lateral incision can be made, or no incision can be made at all, and the decision can be made based on the development of the calf. Devinke's leg originally belonged to the latter, and the recovery was generally very good, so Kavey never thought of opening it.

The surgical incision has almost healed now, and there is a scar under the skin. If I want to cut from here, I won’t be able to distinguish the position of the fascia, and I will have to make another incision.

The single tibia fracture ended up with three long incisions, which was quite rare in Kavey's many years of experience in emergency surgery. The only thing to be thankful for was that Devinke was in good health and he endured for most of the day without any necrosis of the subcutaneous muscle tissue. If there is no necrosis, there is no need for local debridement, just clean the wound surface.

"The posteromedial incision is the same length from the tibial tuberosity to the top of the medial condyle. After the incision, you can see the shallow (pink) and deep (red) compartments. Continue to cut their fascia along this incision."

Unlike modern times, there was no negative pressure drainage device for large wounds like VSD in the 19th century. Although Kawi had made a simple VSD before, the wound was too large and the oil-soaked gauze had to be completely tied to ensure negative pressure, which was a burden for compartment syndrome.

So Kavi decided to just do a simple cover-up and let the two incisions heal slowly.

This was a conceptual shock to Peon. Isolation from air had always been an important argument in the post-Four-Liquid Theory period: "Just leave it open like this?"

"Just cover it with wet gauze, don't bandage it yet." Kavi put down the scalpel, looked at the muscles gradually expanding and stretching the skin on both sides, and then asked Devinke, "Mr. Devinke, do you feel better?"

These few minutes allowed Devin to see what hell looks like.

But to be honest, the original severe swelling and stinging pain after the incision has eased a lot, and now it is more of a simple wound pain. Just like when he pinched the thigh flesh just now, the pain has changed, the feeling is different, and the tolerance seems to have become stronger.

His voice was a little weak and limp: "Okay, okay???"

"The incision is done." Kavi picked up the needle and thread from the side, "Next, hang a few rows of needle and thread to slowly tighten the incision."

"Still, need to sew it up?" Devinke was fat, and even with a pillow under him when he lay flat, his belly blocked his view, so he couldn't see his right leg clearly. He used to be able to see a little bit by using his waist and neck to exert force, but now he was in so much pain that his whole body was weak and he couldn't move at all.

Kavi asked the intern to get a mirror: "Are you going to leave it open without stitching it?"

The incision on the calf that was almost healed now had two long cuts, and the muscles were bulging, just like the feeling of a tightly wrapped sausage being cut open. Things had come to this point, and Devinke had no other ideas: "Sew it up, sew it up."

In fact, if you think about it carefully, you should doubt the feasibility of suturing.

Since the calf had to be cut open to release the internal pressure due to edema, why would it be necessary to sew it up now? Moreover, after the cut was made, could the skin really be sutured together under such great tension?

Peon felt strange at first, but never mentioned it because he believed that Kavey must have his reasons for doing so. The two interns also reacted later, wanting to ask but not daring to, so they could only keep the question in their minds and wait for Kavey to tell them.

In fact, there was another person in the room who had the same question.

Morisot had been sitting in the corner fiddling with his paintbrush, making the draft while his mind followed Kavi's explanation.

Many people would feel psychologically uncomfortable if a scalpel was used to cut open human flesh without anesthesia, twice. Even though he had experienced the theater of surgery, what happened in the ward just now still frightened Morisot.

However, these effects were not significant, and all the images that should be left on the paper were intact. She felt that she could already touch that layer. She only needed to put all the feelings in her mind onto the canvas to break through it and truly complete a work of her own style.

The top is based on goose yellow, and downwards is the pearly rainbow of the chandelier. Below the light is a thin layer of white, which then instantly turns into the black of the doctors' uniforms, forming a large expanse of darkness.

Although it is black, it is not the pure black of the shadows under the feet and behind, but it needs to show rich and vivid changes under the light. And in this large area of ​​vivid black, Kawi's color must be strongly contrasted, even if it is not the case at the time. Because color does not only represent clothing, but also something deeper that this character refers to.

Kavi must be dressed in white, a white shirt, a blood-stained leather skirt that reflects the white light, a scalpel that shines with a bright white luster, an operating table and a patient covered with a white sheet.
His expression didn't need any special processing at all. Just putting the simplest and calmest expression on his face was enough to highlight his calmness and decisiveness.

As for the others, because the distance was too far before, the part that Moriso missed was found again on the faces of the three doctors in front of him.

The doctors present at the time showed not only surprise, ignorance, helplessness and self-doubt, but also the most basic desire for knowledge hidden under these emotions. Everyone who is willing to watch Kawi's surgery, in addition to some special purposes, will have more or less desire for knowledge.

Morisot was observing the entire operation theater from the perspective of a bystander, and had no feelings about it. But now everyone is in front of her, her brush and thoughts have followed Kavi's operation, and doubts naturally arise.

Why do we need sutures after incision?
"I know you all have questions about why sutures are used for suturing."

Kawi inserted the suture needle and said, "Our ultimate goal is to close the two incisions. It is a bit late to suture after the edema is completely recovered. Here I choose to suture just to hang the suture, and then use a special surgical knot to slowly bring the skin on both sides closer."

"Slowly approaching?"

"It's a slipknot, yes, but it still holds together well."

Kavi first passes through the skin on both sides, crosses the line on one side, then loops the line end with the right hand and the double line end with the left hand, first tying a single knot (AB). Then pass the double line end through the loop end (C), and then tighten it on this side (D).

[The red line can be seen as the skin on both sides of the incision]
"You can see that the whole knot can be tightened flexibly, but it can also bear some tension on the skin." Kavi demonstrated again next to the knot, "We tighten it a little bit every day to allow the skin to gradually close together. When it is completely closed (E), tie 2-3 square knots behind the original knot to fix it (F)."

"When tying the knot, you need to observe the blood flow around the skin edge. If you find that the skin edge is white, it means that the tension of the knot is too high. You need to reduce the tension and tie the knot again."

Kavi made three knots in a row, and then handed the rest to Peon: "Cover the wound with gauze soaked in the medicine I brought, and tighten it every 1-3 days. Remember to rinse the wound with saline before tightening to prevent blood from clotting on the thread."

This is a surgical knot invented by Dr. Pascal Boileau, a French shoulder joint expert and one of the three masters of artificial shoulder replacement surgery and shoulder arthroscopic surgery. It is a very practical knotting method because it can achieve self-locking sliding, slowly tighten the skin, and finally achieve a closed effect.

It was introduced and promoted in China by Professor Fu Zhongguo of Peking University People's Hospital. Later, this high-tension knot was named after the French city where he lived, Nice, and was called the Nice knot.

Kavi naturally would not have thought of naming a modern medical method in the 19th century. All he wanted to do was to promote surgery and technical operations. But for others, especially those involved in medical treatment, this was an extremely amazing innovation, which took the wound skin suture a big step forward.

Peon and the two interns might have gotten used to it by now, and Landreth, who entered the ward later, knew it even better.

In the whole room, Morisot was probably the only one who didn't know much about Kavi. Seeing that the incision was completed and the knotting was almost taught, she stood up, thanked him a few times and prepared to leave. Before leaving, Morisot couldn't help but ask casually: "What an amazing knotting method, the operation is so simple that even I can understand it. Is this original creation of Dr. Kavi?"

Payon wanted to answer, but was immediately stopped by Kawi: "Before coming to Paris this year, I went to Marseille and saved a little boy who fell and was injured when I passed by Nice. I didn't have anything with me, so I carried him to a local small clinic for treatment. The old doctor there tied very interesting knots, so I secretly learned it from him."

"Small clinic?" Peon frowned, certainly not believing it.

Landreth didn't even bother to listen. He just suppressed the sneer in his throat and drew all the knotting techniques.

The other two interns also found it odd, but since they had been taught the knot-tying exercises, they had neither the time nor the mood to study such things.

The only one who believed in Kavi might be Morisot.

She packed up her paintbrushes and sketchbook and asked seriously, "That's amazing. What's his name?"

"Pascal Boillot is also a master at treating trauma." At this point, Kavi finally rounded things off, "Small clinics in rural towns always have surprises hidden, as long as you have a heart that is good at discovering."

"Twenty years ago, I studied classical painting with several teachers. Ten years ago, I admired Mr. Manet's techniques and liked the avant-garde style, but Mr. Manet said I was wrong. It was not until recently that I really understood Mr. Edouard Manet's words, 'No matter what style, it is meaningless in front of a good enough model.'" - "Berthe Morisot Notebook 1867-1872", Marmottan Art Museum

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